Whose Life Is It, Anyway?
“Frequent fliers” raise treatment issues, for which there are no easy answers.
This time she almost died.
However, when I encountered Veronique in her ICU room,
she did not seem to appreciate that reality.
“I want a hamburger,” she said, casually
sitting up in bed with her needle-scarred legs dangling
off the side. She was breathing comfortably with her
supplemental nasal oxygen tubes propped uselessly on
Veronique is 28 years old, though she looks about
40. And I write this column feeling an odd tension
of emotions. I tell her story knowing that by the time
this publication reaches your kitchen counter, she
may not be alive.
Veronique’s illnesses are not medical mysteries.
Her eventual demise will not be the result of a rare,
untreatable condition. We know precisely what she has
and what course of treatment she needs.
Six hours before she looked at me and placed her dinner
order, paramedics had rolled Veronique into the critical
care bay in the Hopkins emergency room. She was in
profound respiratory distress, with life-threatening
electrolyte imbalances in her body. She required emergent
hemodialysis, which she promptly received. As a substitute
for her kidneys, which had long since been rendered
inactive by years of high blood pressure, HIV infection
and illicit drug use, dialysis removed the fluid in
her lungs and cleared the excessively dangerous levels
of potassium in her bloodstream.
Dialysis is not new for Veronique. For the past few
years, she has had three scheduled outpatient dialysis
sessions per week. The trouble has been her attendance
record, and her behavior when she chooses to attend.
A longtime crack addict, she regularly shows up high
and just as frequently becomes verbally abusive toward
staff and other patients. When she recently took a
swing at a staffer, she was ordered to leave the facility
and told she would not be welcomed back again.
My team’s experience on the inpatient side of
her care has followed a similarly discouraging pattern.
In the absence of an outpatient dialysis slot, Veronique
comes to the E.R. when she gets short of breath. She
is subsequently admitted for dialysis. For the first
48 hours, she is relatively cooperative.
But once she is dialyzed, her condition improves and
she feels better. Shortly thereafter, she reverts to
her baseline personality, showing disrespect and scorn
toward nurses, medical technicians and her physicians.
She curses. She yells. She makes unreasonable demands.
She interferes with the care we attempt to provide
others. These violations give us little choice but
to administratively discharge her from the hospital
(a nice way of saying “forcibly remove”)
before we can connect her with resources that might
actually make a real difference, like psychiatry and
substance abuse specialists.
Three days later, she’s back, having just smoked
crack. The story repeats itself.
It is fashionable and morally relativist to assert
that we have simply failed as her doctors, as we should
be responsible for narrowing the gap between our therapeutic
tools and a patient’s willingness to accept our
interventions. This premise is a motivating one. It
obligates us to continuously refine and adjust our
method of communicating until we get through to a patient
and to then enlist that individual in a plan of care.
But Veronique’s experience shows that not only
is this premise naïve, it is also fatally flawed.
Why? Because it relieves individuals of the obligation
to take on some semblance of responsibility for their
own well-being. We can point Veronique in the right
direction, but she is an adult with decision-making
capacity. Armed with the necessary medical recommendations,
she makes bad decisions that are tragically her own.
So why are she and I in this situation? There are
factors beyond my failure thus far in getting through
to Veronique, factors beyond her failure to thus far
take commensurate responsibility for her life. For
reasons that extend far beyond the scope of an 800-word
column, the city of Baltimore is home to a citizenry
often facing a jarring collision of social and medical
If any part of staying healthy depends on having functional
family support structures, safe neighborhoods outside
the lethal clouds of drugs and guns, quality schools
where kids have a chance to actually escape the poverty
trap and a local economic infrastructure offering advancement
rather then stagnation, then the medical cases we see
here as residents come as no great surprise.
If for no other reason than to prevent Veronique and
others from falling into such tragic circumstances,
we have every obligation to make this and other American
cities into safer, less destructive environments. And
we have every obligation as doctors to tirelessly attempt
to connect with every patient, hardened, unpleasant,
Whether Veronique then responds is up to her.
It may be too late for Veronique. Every time she leaves
the hospital, I wonder whether I will see her alive
again. I hope I do.
Dan Munoz is a third-year resident
in the Department of Medicine.